Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres Self-compassion in somatoform disorder Charlotte Dewsaran-van der Ven a,b, ⁎ , Saskia van Broeckhuysen-Kloth a , Shiva Thorsell a , Ron Scholten a , Véronique De Gucht a,c , Rinie Geenen a,b, ⁎ a Altrecht Psychosomatic Medicine Eikenboom, Vrijbaan 2, 3705 WC Zeist, The Netherlands b Department of Psychology, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands c Health, Medical and Neuropsychology Unit, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands ARTICLE INFO Keywords: Cognitive-behavioral therapy Common humanity Health-related quality of life Mindfulness Physical symptoms Self-kindness Somatic symptom disorder ABSTRACT ‘Third wave’ cognitive-behavioral therapies have given a boost to the study of resilience factors, such as self- compassion. To get an indication of the potential clinical relevance of self-compassion for somatoform disorder, this study examined whether self-compassion in patients with somatoform disorder is lower than in the general population, and whether self-compassion is associated with number of symptoms and health-related quality of life. Two-hundred-and-thirty-six participants with somatoform disorder and 236 subjects from the general po- pulation, matched on sex and age, filled out questionnaires regarding self-compassion (SCS), number of symp- toms (PSC) and health-related quality of life (EQ-5D). The difference in self-compassion between the patient group (Mean 3.53, SD .96) and the general population (Mean 4.16, SD .98) was significant with a medium effect size (d = −.65). Multiple regression analyses showed that having a somatoform disorder and low self-com- passion were independently associated with number of symptoms and reduced health-related quality of life. The lower level of self-compassion in somatoform disorder and its association with more physical symptoms and lower health-related quality of life, indicate that self-compassion is a potential clinically relevant factor that may influence therapy outcome and that can be a therapeutic target in patients with somatoform disorder. 1. Introduction The positive psychology movement and ‘third wave’ cognitive-be- havioral therapies (CBT) have given a boost to the study of resilience factors in people, such as acceptance and mindfulness, but also self- compassion (Hayes et al., 2011; Bolier et al., 2013). Three interrelated components of self-compassion are thought to help a person during times of pain and failure (Neff, 2003a): (a) self-kindness: being kind and understanding toward oneself rather than being harshly self-critical, (b) common humanity: perceiving one's experiences as part of the larger human experience rather than seeing them as separating and isolating, and (c) mindfulness: holding one's painful thoughts and feelings in balanced awareness rather than over-identifying with them. If low self- compassion is a frequent phenomenon in somatoform disorder, this would suggest that self-compassion might be relevant for this group and could, for instance, be studied as a determinant of therapy outcome. Moreover, this might indicate that it could be useful to offer self-com- passion training to patients with somatoform disorder and low self- compassion. Somatoform disorder, the precursor diagnostic classification of so- matic symptom disorder, is characterized by persistent physical symptoms that suggest the presence of a medical condition, but are not explained fully by this condition or by the direct effects of a substance or another mental disorder (American Psychiatric Association, 2000). The prevalence of somatoform disorder in the general population is about 6% (Wittchen et al., 2011). Psychological or multidisciplinary treatment has been proposed as the preferred treatment option for so- matoform disorder, given the medically untreatable nature of the physical symptoms, and the disturbed behavioral, cognitive and emo- tional processes (Bass and Murphy, 1995; Kroenke, 2007). Meta-ana- lyses have indicated that psychological treatment is beneficial for pa- tients with somatoform disorder but that there is ample room for improvement of effects (Kroenke, 2007; Abbas et al., 2009; Kleinstäuber et al., 2011; Koelen et al., 2014). Theoretical considerations and empirical research suggest that at- tention to and misinterpretation of symptoms, rumination, deficits in mentalizing abilities and emotional awareness, and insecure attach- ment styles are factors that contribute to the development and persis- tence of somatoform disorder (Barsky, 1992; Stuart and Noyes, 1999; Kolk et al., 2003; Brown, 2004; Rief and Sharpe, 2004; Waller and Hartmann, 2004; Rief and Barsky, 2005; Bailer et al., 2006; Deary et al., 2007; Rief and Broadbent, 2007; Subic-Wrana et al., 2010; Witthöft and https://doi.org/10.1016/j.psychres.2017.12.013 Received 17 May 2017; Received in revised form 6 November 2017; Accepted 7 December 2017 ⁎ Correspondence to: Utrecht University, Department of Psychology, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands. E-mail addresses: [email protected] (C. Dewsaran-van der Ven), [email protected] (R. Geenen).
Self-compassion in somatoform disorder
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Self-compassion in somatoform disorderPsychiatry Research
a Altrecht Psychosomatic Medicine Eikenboom, Vrijbaan 2, 3705 WC Zeist, The Netherlands bDepartment of Psychology, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands cHealth, Medical and Neuropsychology Unit, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands
A R T I C L E I N F O
Keywords: Cognitive-behavioral therapy Common humanity Health-related quality of life Mindfulness Physical symptoms Self-kindness Somatic symptom disorder
A B S T R A C T
‘Third wave’ cognitive-behavioral therapies have given a boost to the study of resilience factors, such as self- compassion. To get an indication of the potential clinical relevance of self-compassion for somatoform disorder, this study examined whether self-compassion in patients with somatoform disorder is lower than in the general population, and whether self-compassion is associated with number of symptoms and health-related quality of life. Two-hundred-and-thirty-six participants with somatoform disorder and 236 subjects from the general po- pulation, matched on sex and age, filled out questionnaires regarding self-compassion (SCS), number of symp- toms (PSC) and health-related quality of life (EQ-5D). The difference in self-compassion between the patient group (Mean 3.53, SD .96) and the general population (Mean 4.16, SD .98) was significant with a medium effect size (d = −.65). Multiple regression analyses showed that having a somatoform disorder and low self-com- passion were independently associated with number of symptoms and reduced health-related quality of life. The lower level of self-compassion in somatoform disorder and its association with more physical symptoms and lower health-related quality of life, indicate that self-compassion is a potential clinically relevant factor that may influence therapy outcome and that can be a therapeutic target in patients with somatoform disorder.
1. Introduction
The positive psychology movement and ‘third wave’ cognitive-be- havioral therapies (CBT) have given a boost to the study of resilience factors in people, such as acceptance and mindfulness, but also self- compassion (Hayes et al., 2011; Bolier et al., 2013). Three interrelated components of self-compassion are thought to help a person during times of pain and failure (Neff, 2003a): (a) self-kindness: being kind and understanding toward oneself rather than being harshly self-critical, (b) common humanity: perceiving one's experiences as part of the larger human experience rather than seeing them as separating and isolating, and (c) mindfulness: holding one's painful thoughts and feelings in balanced awareness rather than over-identifying with them. If low self- compassion is a frequent phenomenon in somatoform disorder, this would suggest that self-compassion might be relevant for this group and could, for instance, be studied as a determinant of therapy outcome. Moreover, this might indicate that it could be useful to offer self-com- passion training to patients with somatoform disorder and low self- compassion.
Somatoform disorder, the precursor diagnostic classification of so- matic symptom disorder, is characterized by persistent physical
symptoms that suggest the presence of a medical condition, but are not explained fully by this condition or by the direct effects of a substance or another mental disorder (American Psychiatric Association, 2000). The prevalence of somatoform disorder in the general population is about 6% (Wittchen et al., 2011). Psychological or multidisciplinary treatment has been proposed as the preferred treatment option for so- matoform disorder, given the medically untreatable nature of the physical symptoms, and the disturbed behavioral, cognitive and emo- tional processes (Bass and Murphy, 1995; Kroenke, 2007). Meta-ana- lyses have indicated that psychological treatment is beneficial for pa- tients with somatoform disorder but that there is ample room for improvement of effects (Kroenke, 2007; Abbas et al., 2009; Kleinstäuber et al., 2011; Koelen et al., 2014).
Theoretical considerations and empirical research suggest that at- tention to and misinterpretation of symptoms, rumination, deficits in mentalizing abilities and emotional awareness, and insecure attach- ment styles are factors that contribute to the development and persis- tence of somatoform disorder (Barsky, 1992; Stuart and Noyes, 1999; Kolk et al., 2003; Brown, 2004; Rief and Sharpe, 2004; Waller and Hartmann, 2004; Rief and Barsky, 2005; Bailer et al., 2006; Deary et al., 2007; Rief and Broadbent, 2007; Subic-Wrana et al., 2010; Witthöft and
https://doi.org/10.1016/j.psychres.2017.12.013 Received 17 May 2017; Received in revised form 6 November 2017; Accepted 7 December 2017
Correspondence to: Utrecht University, Department of Psychology, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands. E-mail addresses: [email protected] (C. Dewsaran-van der Ven), [email protected] (R. Geenen).
Hiller, 2010; Landa et al., 2012a, 2012b; Ravesteijn et al., 2014; Luyten et al., 2017). Attention to and misinterpretation of symptoms and ru- mination are difficult to stop unless symptoms improve (Brown, 2004); simply telling people to suppress these processes may have the para- doxical effect of increasing them (Wegner et al., 1987). Instead, the mindfulness component of self-compassion, can be considered the an- tipole of attention to and misinterpretation of symptoms and rumina- tion, because it involves being aware of one's present moment experi- ence in a clear and balanced way and being open to one's suffering instead of avoiding or disconnecting from it (Neff, 2003a). This awareness and openness may perhaps help to increase emotional awareness that has been indicated to be decreased in somatoform dis- order (Subic-Wrana et al., 2010) and to reduce rumination, which is a repetitive form of thinking about possible causes, meanings and im- plications of one's mood, behavior or illness that includes being self- critical (Raes, 2010). Thus, the mindfulness component of self-com- passion may be an antidote against several core aspects of somatoform disorder.
Also self-kindness and common humanity may be resilience factors in somatoform disorder. Instead of being harshly critical or judgmental toward oneself, self-kindness involves the tendency to be mild, under- standing and caring with oneself (Neff, 2009). A negative correlation between scores on the Self-Compassion Scale (SCS) and rumination has indeed been observed (Raes, 2010). Furthermore, insecure attachment that goes with fear of interpersonal relationships and mistrust towards others has been indicated to play a role in somatoform disorder (Koelen et al., 2015). The self-compassion component common humanity is the opposite of poor interpersonal relations and mistrust because it involves feeling connected to others and recognizing that all humans are im- perfect, and experience suffering and failure. It entails seeing one's own shortcomings and difficulties in the greater perspective of the common human condition. (Neff, 2003a; Neff, 2009; Neff and Vonk, 2009). Therefore, compassion training involving self-kindness, mindfulness and common humanity might counterbalance processes that play a role in somatoform disorder by helping patients being aware of one's present moment in a balanced, understanding and caring way, feeling con- nected to others and seeing one's own suffering in the greater per- spective of the common human condition (Neff, 2003a; Neff, 2009; Neff and Vonk, 2009; Raes, 2010) To get an indication of the potential usefulness of this approach, a first step is to determine whether low self- compassion is prevalent and related to symptoms, well-being and functioning in somatoform disorder.
The study of self-compassion in somatoform disorder is supported by a growing body of evidence that self-compassion may be a buffer against mental disorders (MacBeth and Gumley, 2012; Muris and Petrocchi, 2017) and the consideration that patients with this disorder may have a persisting focus on avoiding physical and emotional harm, instead of a mindful, friendly and accepting stance towards their own suffering (Lind et al., 2014; Huang et al., 2016). The aim of the current study was to gain insight into the relevance of self-compassion in so- matoform disorder. To that aim, levels of self-compassion were com- pared between a patient group diagnosed with somatoform disorder (DSM-IV-TR; American Psychiatric Association, 2000) and the general population. We also examined whether there was a correlation between the degree of self-compassion and physical symptoms and health-re- lated quality of life, both in the patient group and the general popu- lation. It was expected that the somatoform disorder group would have a lower level of self-compassion than the general population and that lower levels of self-compassion would be associated with more physical symptoms and lower health-related quality of life.
2. Methods
2.1. Participants
The two samples of this study consisted of 236 patients with
somatoform disorder and 236 people from the general population matched on gender, age and education level.
2.1.1. Patient group The participants from the patient group were recruited at Altrecht
Psychosomatic Medicine, Zeist, The Netherlands, a specialized treat- ment center for patients diagnosed with somatoform disorder according to DSM-IV-TR criteria (American Psychological Association, 2000). Patients admitted to this institution on average have medically un- explained symptoms for 10 years, received about 5 previous treatments for somatoform disorder in primary or secondary care, and have co- morbid mood, anxiety, or personality disorder in about half of the cases (Van der Boom and Houtveen, 2014). Patients with hypochondria, body dysmorphic disorder, addiction, psychosis, and patients in a crisis si- tuation are not treated in the center, and were therefore not included in the current study. Also excluded were patients who did not complete the Self-Compassion Scale (SCS). This resulted in a final sample of 236 participants (64 men and 172 women). The mean age of the sample was 40.8 (SD = 11.7).
2.1.2. General population Participants from the general population were recruited by sending
e-mails and posting messages on Facebook pages. A heterogeneous sample in terms of age, gender, regional area and social background was contacted by sharing calls to participate at Facebook pages of the target audience. Several disorders were excluded because of overlap with somatoform disorder: fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome and chronic pain disorders. These disorders were measured by asking the participants to specify for which disorders they are being treated by a medical doctor. The total number of re- spondents from the general population was N = 399 of which N = 47 were excluded because of an overlapping disorder and N = 116 were excluded in the matching procedure. The final sample consisted of 236 participants (64 men and 172 women). The mean age was 40.6 (SD = 12.4).
2.2. Procedure
2.2.1. Ethical permission The study protocol was approved by the Faculty Ethics Committee
(FETC) of the faculty of Social and Behavioral Sciences at Utrecht University (November 2015, FETC 15-072). Informed consent re- garding the completion of the questionnaire and its purposes was re- quired for inclusion in this study. In the descriptive, correlational study, the following questionnaires were administered: The Self-Compassion Scale (SCS), the Physical Symptom Checklist (PSC; Van Hemert, 2003), and the EuroQol 5-Dimensional (EQ-5D; The EuroQol Group, 1990). Table 1 shows an overview of the available questionnaires per group.
2.2.2. Patient group The PSC and EQ-5D are part of Routine Outcome Monitoring (ROM)
during the intake procedure at Altrecht Psychosomatic Medicine. The SCS was administered for the purpose of this study. Not all patients completed the PSC and the EQ-5D on the same day as the SCS. In that
Table 1 Overview of the available questionnaires for the patient group and the general popula- tion.
Patients General population
Note: SCS = Self-Compassion Scale; PSC = Physical Symptom Checklist; EQ-5D = EuroQol 5-Dimensional.
C. Dewsaran-van der Ven et al.
case the questionnaires administered closest in time to the SCS were used in the analyses. The number of days between filling out the SCS and the PSC and EQ. 5D was entered in the analyses as a control variable.
2.2.3. General population Short recruitment texts with a link to the online questionnaire on
www.qualtrics.com were distributed on the Internet by sending e-mails and posting messages on Facebook. After being informed, signing for informed consent was the only way to open the questionnaire. Respondents provided demographics (age, gender, education, marital status, and zip code), were asked to specify for which disease they were being treated by a medical doctor, and filled out the PSC, EQ-5D and SCS. Responses were stored online anonymously.
2.2.4. Matching procedure After excluding participants in the general population with medi-
cally unexplained symptoms, random numbers generated by SPSS were allocated to the participants that were eligible for the general popula- tion sample (N = 352). Everyone in the patient group was matched to one participant of the general population on the basis of gender, age and education level. Gender necessarily had to be the same. Age pre- ferably also had to be equal, but if this wasn’t possible, someone closest in age was chosen. Whenever possible the same level of education was chosen, or otherwise the level that was closest. In case of multiple possible matches, the lowest random number was chosen.
2.3. Materials
2.3.1. SCS The Dutch translation of the SCS (Neff, 2003b; Neff and Vonk, 2009)
is a 24 item questionnaire consisting of six scales that assess the positive and negative poles of the three components of self-compassion: Self- kindness (e.g. ‘When I am going through a very hard time, I give myself the caring and tenderness I need’), Self-Judgement (e.g. ‘I am dis- approving and judgmental about my own flaws and inadequacies’), Common Humanity (e.g. ‘I try to see my feelings as part of the human condition’), Isolation (e.g. ‘When I fail at something that is important to me, I tend to feel alone in my failure’), Mindfulness (e.g. ‘When something upsets me I try to keep my emotions in balance’) and Over- Identification (e.g. ‘When I am feeling down I tend to obsess and fixate on everything that is wrong’) (Neff, 2003b). Items are rated on a seven- point Likert scale, ranging from 1 (almost never) to 7 (almost always). The SCS has a good internal consistency, construct validity, test-retest reliability and discriminant validity (Neff, 2003b). In the current study, Cronbach's α of the total SCS score was .92. Cronbach's α of the sub- scales varied from .75 (common humanity) to .87 (self-kindness). This suggests an acceptable to good internal consistency.
2.3.2. PSC The PSC (Van Hemert, 2003) is a checklist comprising 51 items of
physical symptoms (e.g. palpitations, insomnia, myalgia, nausea, ab- dominal pains, and headaches) that are all included in the DSM-IV-TR (American Psychological Association, 2000; De Waal et al., 2009). Each symptom is rated on a four-point Likert scale reflecting the frequency of the symptoms during the previous week: never (0), sometimes (1), regularly (2) and often (3). The lowest answering categories (0 and 1) are scored as 0 and the highest categories (2 and 3) are scored as 1. Cronbach's alpha at the PSC is in the current study was .95 which is a very good internal consistency.
2.3.3. EQ-5D The EQ-5D (The EuroQol Group, 1990) measures health-related
quality of life using verbal descriptions and the EQ visual analogue scale (EQ VAS). The descriptive system comprises the following 5 di- mensions: mobility, self-care, usual activities, pain/discomfort and
anxiety/depression. Each dimension has 3 levels: no problems, some problems, extreme problems. The combination of the five scores defines 243 health states that are weighted and contribute to an index score between −.33 (worst possible health state) and 1.00 (best possible health state). The EQ VAS records the respondent's self-rated health on a scale ranging from 0 (= best imaginable health state) to 100 (= worst imaginable health state). Validity research in a population with soma- toform disorder shows a good convergent validity of the EQ-5D and discrimination between patients with somatoform disorder and the general population (Brettschneider et al., 2013). In the current study, Cronbach's α at the EQ-5D was .80 which reflects a good internal consistency.
2.4. Data analysis
Statistical analyses were performed using IBM SPSS statistics ver- sion 23.0. All tests were two-tailed and statistical significance was considered for p< .05. An independent samples t-test was used for examining differences in self-compassion (total score and subscales) between the patient group and the general population. In case of multiple tests, also Bonferroni corrected p-values are reported. Effect sizes (Cohen's d) were computed using the means and standard devia- tions of the general population as reference values. Values of .2, .5 and .8 represent small, medium and large deviations, respectively. We also did this for women and men separately, because a meta-analyses showed that men have slightly higher levels of self-compassion than females (Yarnell et al., 2015).
To test the associations between self-compassion and number of symptoms, and self-compassion and physical impairment, multiple re- gression analyses were performed. Group (patient vs. control), self- compassion (total score SCS), and the interaction self-compassion × group were entered as predictors for number of symptoms (PSC) or physical impairment (EQ-5D). Gender, age and the number of days between measurements were added as covariates.
2.4.1. Ad hoc analyses Since the descriptive analyses showed significant differences in
education level between the groups, with more highly educated in- dividuals in the general population, analyses were conducted again for two samples of 124 participants that were perfectly matched on edu- cation level. In these analyses, the total samples were again used to match the samples perfectly on gender and education level.
3. Results
3.1. Description of the samples
Table 2 shows the characteristics of both groups. Age was not per- fectly matched but the mean age did not differ between both groups. The education level of only 127 people in the patient group was known because this was not included in the electronic patient file by default. Education level of the groups differed significantly, with more people with high education being included in the general population sample.
3.2. Levels of self-compassion
Table 3 shows the levels of self-compassion for the samples. An independent samples t-test showed significant differences in total scores on the SCS between the patient group and the general population, t (458) = −6.96, p< .001. The groups differed significantly from each other on every subscale: self-kindness (t (464) = −6.99, p< .001), self-judgment (t (469) = 6.17, p< .001), common humanity (t (468) = −6.37, p< .001), isolation (t (466) = 3.55, p< .001), mindfulness (t (466) = −4.68, p< .001), over identification (t (469) = 3.12, p< .01); the group differences with a p-value< .001 remained sig- nificant after Bonferroni correction. The magnitude of differences
C. Dewsaran-van der Ven et al.
3.3. Levels of self-compassion associated with physical symptoms and health-related quality of life
The mean score on the PSC was 17.00 (SD = 8.29) for the patient group and 7.78 (SD = 8.56) for the control group. The mean score on the EQ-5D was .38 (SD = .33) for the patient group and .75 (SD = .28) for the control group. These differences between groups were highly significant (p< .001).
The results of multiple regression analyses examining the associa- tion of self-compassion with number of symptoms and health-related quality of life are shown in Table 4. Female gender was associated with more physical symptoms (p< .001) and a lower health-related quality of life (p = .001). Also a higher age was associated with more physical symptoms (p= .01) and a lower health-related quality of life (p= .01). The time interval between measurement of the SCS and PSC or EQ-5D was neither significantly associated with physical symptoms (p = .88), nor with health-related quality of life (p = .51), suggesting that
Table 2 Descriptive variables of the patient group and the general population.
Variable Patient Group General Population
Gender Men 64 64 Women 172 172
Age Range 18–67 18–68 Mean 40.8 40.6 Standard deviation 11.74 12.4
Educational Level Low 16 9 Medium 60 87 High 51 140 Unknown 109 0
Total 236 236
Note. Education level: low: primary school or lower vocational secondary education; middle: intermediate general secondary education or intermediate vocational education; high: higher general secondary education, higher vocational education, or university education. The mean age did not differ between groups: t (470) =−.13, p= .90; the education level differed significantly: χ2 (2) = 17.21, p<.001.
Table 3 Means (M), standard deviations (SD) and Cohen's d effect sizes of…
a Altrecht Psychosomatic Medicine Eikenboom, Vrijbaan 2, 3705 WC Zeist, The Netherlands bDepartment of Psychology, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands cHealth, Medical and Neuropsychology Unit, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands
A R T I C L E I N F O
Keywords: Cognitive-behavioral therapy Common humanity Health-related quality of life Mindfulness Physical symptoms Self-kindness Somatic symptom disorder
A B S T R A C T
‘Third wave’ cognitive-behavioral therapies have given a boost to the study of resilience factors, such as self- compassion. To get an indication of the potential clinical relevance of self-compassion for somatoform disorder, this study examined whether self-compassion in patients with somatoform disorder is lower than in the general population, and whether self-compassion is associated with number of symptoms and health-related quality of life. Two-hundred-and-thirty-six participants with somatoform disorder and 236 subjects from the general po- pulation, matched on sex and age, filled out questionnaires regarding self-compassion (SCS), number of symp- toms (PSC) and health-related quality of life (EQ-5D). The difference in self-compassion between the patient group (Mean 3.53, SD .96) and the general population (Mean 4.16, SD .98) was significant with a medium effect size (d = −.65). Multiple regression analyses showed that having a somatoform disorder and low self-com- passion were independently associated with number of symptoms and reduced health-related quality of life. The lower level of self-compassion in somatoform disorder and its association with more physical symptoms and lower health-related quality of life, indicate that self-compassion is a potential clinically relevant factor that may influence therapy outcome and that can be a therapeutic target in patients with somatoform disorder.
1. Introduction
The positive psychology movement and ‘third wave’ cognitive-be- havioral therapies (CBT) have given a boost to the study of resilience factors in people, such as acceptance and mindfulness, but also self- compassion (Hayes et al., 2011; Bolier et al., 2013). Three interrelated components of self-compassion are thought to help a person during times of pain and failure (Neff, 2003a): (a) self-kindness: being kind and understanding toward oneself rather than being harshly self-critical, (b) common humanity: perceiving one's experiences as part of the larger human experience rather than seeing them as separating and isolating, and (c) mindfulness: holding one's painful thoughts and feelings in balanced awareness rather than over-identifying with them. If low self- compassion is a frequent phenomenon in somatoform disorder, this would suggest that self-compassion might be relevant for this group and could, for instance, be studied as a determinant of therapy outcome. Moreover, this might indicate that it could be useful to offer self-com- passion training to patients with somatoform disorder and low self- compassion.
Somatoform disorder, the precursor diagnostic classification of so- matic symptom disorder, is characterized by persistent physical
symptoms that suggest the presence of a medical condition, but are not explained fully by this condition or by the direct effects of a substance or another mental disorder (American Psychiatric Association, 2000). The prevalence of somatoform disorder in the general population is about 6% (Wittchen et al., 2011). Psychological or multidisciplinary treatment has been proposed as the preferred treatment option for so- matoform disorder, given the medically untreatable nature of the physical symptoms, and the disturbed behavioral, cognitive and emo- tional processes (Bass and Murphy, 1995; Kroenke, 2007). Meta-ana- lyses have indicated that psychological treatment is beneficial for pa- tients with somatoform disorder but that there is ample room for improvement of effects (Kroenke, 2007; Abbas et al., 2009; Kleinstäuber et al., 2011; Koelen et al., 2014).
Theoretical considerations and empirical research suggest that at- tention to and misinterpretation of symptoms, rumination, deficits in mentalizing abilities and emotional awareness, and insecure attach- ment styles are factors that contribute to the development and persis- tence of somatoform disorder (Barsky, 1992; Stuart and Noyes, 1999; Kolk et al., 2003; Brown, 2004; Rief and Sharpe, 2004; Waller and Hartmann, 2004; Rief and Barsky, 2005; Bailer et al., 2006; Deary et al., 2007; Rief and Broadbent, 2007; Subic-Wrana et al., 2010; Witthöft and
https://doi.org/10.1016/j.psychres.2017.12.013 Received 17 May 2017; Received in revised form 6 November 2017; Accepted 7 December 2017
Correspondence to: Utrecht University, Department of Psychology, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands. E-mail addresses: [email protected] (C. Dewsaran-van der Ven), [email protected] (R. Geenen).
Hiller, 2010; Landa et al., 2012a, 2012b; Ravesteijn et al., 2014; Luyten et al., 2017). Attention to and misinterpretation of symptoms and ru- mination are difficult to stop unless symptoms improve (Brown, 2004); simply telling people to suppress these processes may have the para- doxical effect of increasing them (Wegner et al., 1987). Instead, the mindfulness component of self-compassion, can be considered the an- tipole of attention to and misinterpretation of symptoms and rumina- tion, because it involves being aware of one's present moment experi- ence in a clear and balanced way and being open to one's suffering instead of avoiding or disconnecting from it (Neff, 2003a). This awareness and openness may perhaps help to increase emotional awareness that has been indicated to be decreased in somatoform dis- order (Subic-Wrana et al., 2010) and to reduce rumination, which is a repetitive form of thinking about possible causes, meanings and im- plications of one's mood, behavior or illness that includes being self- critical (Raes, 2010). Thus, the mindfulness component of self-com- passion may be an antidote against several core aspects of somatoform disorder.
Also self-kindness and common humanity may be resilience factors in somatoform disorder. Instead of being harshly critical or judgmental toward oneself, self-kindness involves the tendency to be mild, under- standing and caring with oneself (Neff, 2009). A negative correlation between scores on the Self-Compassion Scale (SCS) and rumination has indeed been observed (Raes, 2010). Furthermore, insecure attachment that goes with fear of interpersonal relationships and mistrust towards others has been indicated to play a role in somatoform disorder (Koelen et al., 2015). The self-compassion component common humanity is the opposite of poor interpersonal relations and mistrust because it involves feeling connected to others and recognizing that all humans are im- perfect, and experience suffering and failure. It entails seeing one's own shortcomings and difficulties in the greater perspective of the common human condition. (Neff, 2003a; Neff, 2009; Neff and Vonk, 2009). Therefore, compassion training involving self-kindness, mindfulness and common humanity might counterbalance processes that play a role in somatoform disorder by helping patients being aware of one's present moment in a balanced, understanding and caring way, feeling con- nected to others and seeing one's own suffering in the greater per- spective of the common human condition (Neff, 2003a; Neff, 2009; Neff and Vonk, 2009; Raes, 2010) To get an indication of the potential usefulness of this approach, a first step is to determine whether low self- compassion is prevalent and related to symptoms, well-being and functioning in somatoform disorder.
The study of self-compassion in somatoform disorder is supported by a growing body of evidence that self-compassion may be a buffer against mental disorders (MacBeth and Gumley, 2012; Muris and Petrocchi, 2017) and the consideration that patients with this disorder may have a persisting focus on avoiding physical and emotional harm, instead of a mindful, friendly and accepting stance towards their own suffering (Lind et al., 2014; Huang et al., 2016). The aim of the current study was to gain insight into the relevance of self-compassion in so- matoform disorder. To that aim, levels of self-compassion were com- pared between a patient group diagnosed with somatoform disorder (DSM-IV-TR; American Psychiatric Association, 2000) and the general population. We also examined whether there was a correlation between the degree of self-compassion and physical symptoms and health-re- lated quality of life, both in the patient group and the general popu- lation. It was expected that the somatoform disorder group would have a lower level of self-compassion than the general population and that lower levels of self-compassion would be associated with more physical symptoms and lower health-related quality of life.
2. Methods
2.1. Participants
The two samples of this study consisted of 236 patients with
somatoform disorder and 236 people from the general population matched on gender, age and education level.
2.1.1. Patient group The participants from the patient group were recruited at Altrecht
Psychosomatic Medicine, Zeist, The Netherlands, a specialized treat- ment center for patients diagnosed with somatoform disorder according to DSM-IV-TR criteria (American Psychological Association, 2000). Patients admitted to this institution on average have medically un- explained symptoms for 10 years, received about 5 previous treatments for somatoform disorder in primary or secondary care, and have co- morbid mood, anxiety, or personality disorder in about half of the cases (Van der Boom and Houtveen, 2014). Patients with hypochondria, body dysmorphic disorder, addiction, psychosis, and patients in a crisis si- tuation are not treated in the center, and were therefore not included in the current study. Also excluded were patients who did not complete the Self-Compassion Scale (SCS). This resulted in a final sample of 236 participants (64 men and 172 women). The mean age of the sample was 40.8 (SD = 11.7).
2.1.2. General population Participants from the general population were recruited by sending
e-mails and posting messages on Facebook pages. A heterogeneous sample in terms of age, gender, regional area and social background was contacted by sharing calls to participate at Facebook pages of the target audience. Several disorders were excluded because of overlap with somatoform disorder: fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome and chronic pain disorders. These disorders were measured by asking the participants to specify for which disorders they are being treated by a medical doctor. The total number of re- spondents from the general population was N = 399 of which N = 47 were excluded because of an overlapping disorder and N = 116 were excluded in the matching procedure. The final sample consisted of 236 participants (64 men and 172 women). The mean age was 40.6 (SD = 12.4).
2.2. Procedure
2.2.1. Ethical permission The study protocol was approved by the Faculty Ethics Committee
(FETC) of the faculty of Social and Behavioral Sciences at Utrecht University (November 2015, FETC 15-072). Informed consent re- garding the completion of the questionnaire and its purposes was re- quired for inclusion in this study. In the descriptive, correlational study, the following questionnaires were administered: The Self-Compassion Scale (SCS), the Physical Symptom Checklist (PSC; Van Hemert, 2003), and the EuroQol 5-Dimensional (EQ-5D; The EuroQol Group, 1990). Table 1 shows an overview of the available questionnaires per group.
2.2.2. Patient group The PSC and EQ-5D are part of Routine Outcome Monitoring (ROM)
during the intake procedure at Altrecht Psychosomatic Medicine. The SCS was administered for the purpose of this study. Not all patients completed the PSC and the EQ-5D on the same day as the SCS. In that
Table 1 Overview of the available questionnaires for the patient group and the general popula- tion.
Patients General population
Note: SCS = Self-Compassion Scale; PSC = Physical Symptom Checklist; EQ-5D = EuroQol 5-Dimensional.
C. Dewsaran-van der Ven et al.
case the questionnaires administered closest in time to the SCS were used in the analyses. The number of days between filling out the SCS and the PSC and EQ. 5D was entered in the analyses as a control variable.
2.2.3. General population Short recruitment texts with a link to the online questionnaire on
www.qualtrics.com were distributed on the Internet by sending e-mails and posting messages on Facebook. After being informed, signing for informed consent was the only way to open the questionnaire. Respondents provided demographics (age, gender, education, marital status, and zip code), were asked to specify for which disease they were being treated by a medical doctor, and filled out the PSC, EQ-5D and SCS. Responses were stored online anonymously.
2.2.4. Matching procedure After excluding participants in the general population with medi-
cally unexplained symptoms, random numbers generated by SPSS were allocated to the participants that were eligible for the general popula- tion sample (N = 352). Everyone in the patient group was matched to one participant of the general population on the basis of gender, age and education level. Gender necessarily had to be the same. Age pre- ferably also had to be equal, but if this wasn’t possible, someone closest in age was chosen. Whenever possible the same level of education was chosen, or otherwise the level that was closest. In case of multiple possible matches, the lowest random number was chosen.
2.3. Materials
2.3.1. SCS The Dutch translation of the SCS (Neff, 2003b; Neff and Vonk, 2009)
is a 24 item questionnaire consisting of six scales that assess the positive and negative poles of the three components of self-compassion: Self- kindness (e.g. ‘When I am going through a very hard time, I give myself the caring and tenderness I need’), Self-Judgement (e.g. ‘I am dis- approving and judgmental about my own flaws and inadequacies’), Common Humanity (e.g. ‘I try to see my feelings as part of the human condition’), Isolation (e.g. ‘When I fail at something that is important to me, I tend to feel alone in my failure’), Mindfulness (e.g. ‘When something upsets me I try to keep my emotions in balance’) and Over- Identification (e.g. ‘When I am feeling down I tend to obsess and fixate on everything that is wrong’) (Neff, 2003b). Items are rated on a seven- point Likert scale, ranging from 1 (almost never) to 7 (almost always). The SCS has a good internal consistency, construct validity, test-retest reliability and discriminant validity (Neff, 2003b). In the current study, Cronbach's α of the total SCS score was .92. Cronbach's α of the sub- scales varied from .75 (common humanity) to .87 (self-kindness). This suggests an acceptable to good internal consistency.
2.3.2. PSC The PSC (Van Hemert, 2003) is a checklist comprising 51 items of
physical symptoms (e.g. palpitations, insomnia, myalgia, nausea, ab- dominal pains, and headaches) that are all included in the DSM-IV-TR (American Psychological Association, 2000; De Waal et al., 2009). Each symptom is rated on a four-point Likert scale reflecting the frequency of the symptoms during the previous week: never (0), sometimes (1), regularly (2) and often (3). The lowest answering categories (0 and 1) are scored as 0 and the highest categories (2 and 3) are scored as 1. Cronbach's alpha at the PSC is in the current study was .95 which is a very good internal consistency.
2.3.3. EQ-5D The EQ-5D (The EuroQol Group, 1990) measures health-related
quality of life using verbal descriptions and the EQ visual analogue scale (EQ VAS). The descriptive system comprises the following 5 di- mensions: mobility, self-care, usual activities, pain/discomfort and
anxiety/depression. Each dimension has 3 levels: no problems, some problems, extreme problems. The combination of the five scores defines 243 health states that are weighted and contribute to an index score between −.33 (worst possible health state) and 1.00 (best possible health state). The EQ VAS records the respondent's self-rated health on a scale ranging from 0 (= best imaginable health state) to 100 (= worst imaginable health state). Validity research in a population with soma- toform disorder shows a good convergent validity of the EQ-5D and discrimination between patients with somatoform disorder and the general population (Brettschneider et al., 2013). In the current study, Cronbach's α at the EQ-5D was .80 which reflects a good internal consistency.
2.4. Data analysis
Statistical analyses were performed using IBM SPSS statistics ver- sion 23.0. All tests were two-tailed and statistical significance was considered for p< .05. An independent samples t-test was used for examining differences in self-compassion (total score and subscales) between the patient group and the general population. In case of multiple tests, also Bonferroni corrected p-values are reported. Effect sizes (Cohen's d) were computed using the means and standard devia- tions of the general population as reference values. Values of .2, .5 and .8 represent small, medium and large deviations, respectively. We also did this for women and men separately, because a meta-analyses showed that men have slightly higher levels of self-compassion than females (Yarnell et al., 2015).
To test the associations between self-compassion and number of symptoms, and self-compassion and physical impairment, multiple re- gression analyses were performed. Group (patient vs. control), self- compassion (total score SCS), and the interaction self-compassion × group were entered as predictors for number of symptoms (PSC) or physical impairment (EQ-5D). Gender, age and the number of days between measurements were added as covariates.
2.4.1. Ad hoc analyses Since the descriptive analyses showed significant differences in
education level between the groups, with more highly educated in- dividuals in the general population, analyses were conducted again for two samples of 124 participants that were perfectly matched on edu- cation level. In these analyses, the total samples were again used to match the samples perfectly on gender and education level.
3. Results
3.1. Description of the samples
Table 2 shows the characteristics of both groups. Age was not per- fectly matched but the mean age did not differ between both groups. The education level of only 127 people in the patient group was known because this was not included in the electronic patient file by default. Education level of the groups differed significantly, with more people with high education being included in the general population sample.
3.2. Levels of self-compassion
Table 3 shows the levels of self-compassion for the samples. An independent samples t-test showed significant differences in total scores on the SCS between the patient group and the general population, t (458) = −6.96, p< .001. The groups differed significantly from each other on every subscale: self-kindness (t (464) = −6.99, p< .001), self-judgment (t (469) = 6.17, p< .001), common humanity (t (468) = −6.37, p< .001), isolation (t (466) = 3.55, p< .001), mindfulness (t (466) = −4.68, p< .001), over identification (t (469) = 3.12, p< .01); the group differences with a p-value< .001 remained sig- nificant after Bonferroni correction. The magnitude of differences
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3.3. Levels of self-compassion associated with physical symptoms and health-related quality of life
The mean score on the PSC was 17.00 (SD = 8.29) for the patient group and 7.78 (SD = 8.56) for the control group. The mean score on the EQ-5D was .38 (SD = .33) for the patient group and .75 (SD = .28) for the control group. These differences between groups were highly significant (p< .001).
The results of multiple regression analyses examining the associa- tion of self-compassion with number of symptoms and health-related quality of life are shown in Table 4. Female gender was associated with more physical symptoms (p< .001) and a lower health-related quality of life (p = .001). Also a higher age was associated with more physical symptoms (p= .01) and a lower health-related quality of life (p= .01). The time interval between measurement of the SCS and PSC or EQ-5D was neither significantly associated with physical symptoms (p = .88), nor with health-related quality of life (p = .51), suggesting that
Table 2 Descriptive variables of the patient group and the general population.
Variable Patient Group General Population
Gender Men 64 64 Women 172 172
Age Range 18–67 18–68 Mean 40.8 40.6 Standard deviation 11.74 12.4
Educational Level Low 16 9 Medium 60 87 High 51 140 Unknown 109 0
Total 236 236
Note. Education level: low: primary school or lower vocational secondary education; middle: intermediate general secondary education or intermediate vocational education; high: higher general secondary education, higher vocational education, or university education. The mean age did not differ between groups: t (470) =−.13, p= .90; the education level differed significantly: χ2 (2) = 17.21, p<.001.
Table 3 Means (M), standard deviations (SD) and Cohen's d effect sizes of…
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